Examination of GI system

Question 1

Overview of examination of GI system

Answer 1

Inspection

Palpation

Percussion

Auscultation

Question 2

Before you begin what do you have to do?

Answer 2

Wash your hands

Introduce yourself

Explain what you would like to do and ask for permission

Ask patient have they any questions

Chaperone

Exposure

Question 3

What do we do in inspection?

Answer 3

Inspect in a systematic manner – start from the end of the bed and work your way from the hands to the face, neck, chest then abdomen

Assess the bed space too! – look for drip stands, catheter bags, inhalers etc

Question 4

What can we realise from the end of the bed?

Answer 4

Is the patient in obvious discomfort or distress?
- Pain
- Tachypnoeic
- Jaundiced/cyanosed

Body habitus
Check the observation chart
Check the fluid balance chart

Question 5

Koilonychia is shown in what

Answer 5

Fe deficient anaemia

Question 6

Leukonychia is seen in what?

Answer 6

hypoalbuminaemia, liver cirrhosis

Question 7

What is nail clubbing seen in?

Answer 7

Nail clubbing – resp, cvs and GI conditions (crohns, UC, cirrhosis)

Question 8

Causes of palmar erythema?

Answer 8

many causes, portal hypertension and cirrhosis in GI tract

Question 9

What is dupuytrens contracture seen in?

Answer 9

alcoholism and liver disease

Question 10

How do we look for a liver flap?

Answer 10

Ask patient to extend their arms out with palms up

Question 11

How to look for jaundice?

Answer 11

Ask patient to pull down their eyelid

Question 12

What is xanthelasma?

Answer 12

Eye skin things

Question 13

Kayser - Fleischer rings are found in…

Answer 13

Wilsons disease

Question 14

What can be found in the mouth?

Answer 14

Angular cheilitis - spots on side of mouth - Fe Deficiency
Glossitis - Swollen red tongue
Mouth ulcers - red spots in mouth

Question 15

What is found on inspection of the chest?

Answer 15

Spider naevi
SVC distribution
Gynaecomastia
Supraclavicular lymph node

Question 16

What to do on inspection of the abdomen?

Answer 16

Ask the patient to lie flat with their hands beside their sides

Describe any scars, stomas, lesions, masses or obvious signs

Comment on whether the abdomen is distended

Don’t forget to mention the presence of drains, catheters etc!

Question 17

Description of abdominal scars

Answer 17

Rooftop
Hypochondrial
Upper midline
Lower midline
Paramedian
Gridiron
Pfannenstiel
Slide 24 on examination of GI system great picture

Question 18

What to comment on for stomas?

Answer 18

Site

Type of bowel

Content

Type of Bag

Question 19

What are the different signs seen on the abdomen?

Answer 19

Cullens sign - bruises near belly button - pancreatitis
Grey’s- Turner sign- Bruises on the side of abdomen - pancreatitis
Caput medusa - portal hypertension

Question 20

How do we palpate the abdomen?

Answer 20

Get down to the patient’s level
Palpate superficially then deep in all 9 regions on the abdomen
Start with the region that is further away from the area that is painful
Palpate the liver, spleen and ballott both kidneys
Palpate for a bladder and abdominal aorta

Question 21

How do we palpate?

Answer 21

Hand flat over each area and flex at the MCP joints

Look at the patients face, not at your hand

Question 22

How do we palpate the liver?

Answer 22

Deep breaths
Palpating hand will feel liver pushed down by the diaphragm in inspiration
Liver can be palpated up to 1cm below the right costal margin on deep inspiration
Gallbladder not normally palpable unless enlarged

Question 23

What is Murphy’s sign?

Answer 23

Ask the patient to exhale

Place hand in right upper quadrant just below costal margin

Ask the patient to inhale

Is positive if the patient is sore/catches breath on inhaling and is possibly a sign of cholecystitis

Question 24

How do we palpate the spleen?

Answer 24

Not normally palpable unless enlarged
Can place left hand posteriorly and roll patient slightly towards you
Begin in the right iliac fossa
Advance towards the left costal margin

Question 25

How do we ballot the kidneys?

Answer 25

Anterior hand lateral to the margin of the rectus in the upper quadrant Posterior hand in the costovertebral angle to lift the kidney up against the anterior hand Lower pole right kidney may be palpable in thin people, left kidney rarely palpable Slide 33 of examination of GI system

Question 26

Big spleen features

Answer 26

Can’t get above Can cross the midline Sometimes can feel a splenic notch Moves down on inspiration Cannot ballott the spleen

Question 27

Big Kidney features

Answer 27

Can get above Doesn’t cross the midline Doesn’t move on respiration Ballotable

Question 28

Palpate the abdominal aorta

Answer 28

Aortic pulsation may be felt in a normal thin person

Question 29

Palpate for a distended bladder

Answer 29

The bladder is only palpable when it has >300ml of urine The patient may describe the sensation of needing to pass urine on palpation of a full bladder

Question 30

What is Rovsing's sign?

Answer 30

Palpation of the left iliac fossa results in pain in the right iliac fossa Can indicate appendicitis

Question 31

Where is percussion found of the liver?

Answer 31

percuss downwards from superior border of 6th rib then upwards from umbilicus in midclavicular line

Question 32

Where is percussion found from the spleen?

Answer 32

percuss in the left anterior axillary line, lowest intercostal space, if changes from resonant to dull on inspiration then splenomegaly

Question 33

Where is percussion of the bladder found?

Answer 33

from pubic symphysis to umbilicus

Question 34

How do you examine shifting dullness?

Answer 34

Palpate abdomen at midclavicular line where you detect dullness and then move over to a different area of the patient to see if the dullness is shifting elsewhere

Question 35

What do you do on auscultation?

Answer 35

Listen for bowel sounds and describe them Listen for aortic and femoral bruits

Question 36

How do we complete the examination? (ISHRUG)

Answer 36

Inguinal lymph nodes Stools Hernial Orifices Rectal Examination Urinalysis Genitalia

Question 37

What do we do at the end?

Answer 37

Thank the patient Ask them to redress Wash your hands!

Question 38

How to do a per rectal examination?

Answer 38

Left lateral position with knees tucked up towards chest Inspect the perianal area for any lesions Insert a gloved well-lubricated finger Assess anal tone Assess rectum for stool or masses Assess size and feel of the prostate Check the gloved finger for blood after removing

Question 39

How do we examine the scrotum?

Answer 39

Inspection Scrotal skin Lie of the testis Palpation - Gentle pressure to palpate the testes, epididymis and cord Transillumination -using a pen torch

Question 40

How to differentiate between the causes of scrotal swellings?

Answer 40

Can I get above the swelling? Can I identify a normal testis? Is the swelling tender? Does the swelling transilluminate?

Question 41

Scrotal swelling - Can i get above the swelling?

Answer 41

NO - (Not a true scrotal swelling) Infantile hydrocele Hernia Yes - True scrotal swelling (PROCEED TO NEXT QUESTION)

Question 42

Scrotal swellings - Can I identify a normal testis?

Answer 42

No -Testicular Tumour, Tense Hydrocele, Orchitis Yes - NOT A TESTICULAR MASS (PROCEED TO NEXT QUESTION)

Question 43

Does the swelling transilluminate in scrotum? (Normal testis)

Answer 43

No - Spermatocele Epididymitis Epididymal tumour Tuberculous epididymitis Yes - Epididymal Cyst Cyst of the cord Lax hydrocele

Question 44

Does the swelling transilluminate in scrotum? (NO Normal testis)

Answer 44

No - Testicular Tumour Haematocele (smooth surface, history of trauma Orchitis (tender) Yes - Hydrocele